AHIMA CDIP, ACDIS CCDS, or AHIMA CCS certification required
8+ years of inpatient CDI experience
5+ years of clinical experience in acute care settings
Strong understanding of ICD-10-CM/PCS coding guidelines
Responsibilities
Educate providers on clinical documentation best practices
Perform audits of medical records for accuracy and compliance
Collaborate with interdisciplinary teams for documentation review
Develop and deliver training presentations
Track and analyze data for performance improvement
Write clinical appeal letters and manage denial processes
Foster relationships with hospital leadership and clinical teams
Benefits
Comprehensive health insurance
Retirement savings plan
Paid time off and holidays
Continuing education opportunities
Supportive work environment focused on professional growth
Full Job Description
Type: Full-Time 75 Hours Bi-Weekly
Shift: Days
Hours: Varies
Salary: $120,000 - $130,000
Position Responsibilities and Functions:
Possesses strong clinical foundation with respect to differential diagnoses, disease interactions, pathophysiology, and treatment protocols.
Demonstrates mastery of ICD-10-CM/PCS coding guidelines.
Serves as liaison between providers and coders with respect to crosswalk between clinical language and coding terminologies.
Educates providers on clinical documentation best practices aligned with ICD-10-CM/PCS Official Guidelines for Coding and Reporting.
Performs audits of medical records to ensure that provider documentation is accurate and complete and that correct ICD-10-CM/PCS codes are captured.
Fosters collaborative relationships with Hospital Leadership, providers, clinical teams, quality teams, compliance teams, and coding team.
Displays excellent oral and written communication skills
Demonstrates proficiency developing and delivering presentations for training and education.
Demonstrates proficiency with DRG grouper software and electronic health records (e.g. Meditech, Epic).
Demonstrates qualities outlined in the "Customer Service Standards of Excellence" program when interacting with patients, their families and friends, and fellow employees.
Maintains compliance with internal and external policies, procedures, regulations, industry guidelines and objectives, HIPAA, and safety standards.
Develops, coordinates, and performs internal auditing activities to ensure compliance with best practices for clinical documentation and coding.
Collaborates with inpatient coders to support accurate APR-DRG and MS-DRG assignment.
Writes clinical appeal letters and supports denial management process.
Generates clinically robust queries for providers and adheres to AHIMA Guidelines for Achieving a Compliant Query Practice.
Communicates with providers to obtain timely and compliant query responses
Tracks, analyzes, and trends data to identify opportunities for performance improvement.
Monitors, tracks, and maintains key CDI metrics.
Educates providers on documentation best practices to ensure the most appropriate and specific ICD-10-CM/PCS codes are captured in accordance with State, Federal, and other accrediting agencies.
Collaborates with interdisciplinary teams to identify opportunities and establish a unified approach for clinical documentation review, audit, and education.
Collaborates with Clinical Applications department to create and implement EMR components for complete and accurate provider clinical documentation and appropriate APR-DRG and MS-DRG assignment.
Designs and presents CDI program metrics to Hospital Leadership.
Leads and/or participates in meetings pertaining to CDI.
